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Monthly Archives: July 2008

There doesn’t seem to be much getting away from the fact that social work is a vaguely paternalistic profession. I touched on this previously and its something that I’ve been dwelling on for a while. Even if the systems and functions have changed today, its roots were in any case. Charity from the state – the distinction between the ‘deserving’ and ‘undeserving’ poor which was made in the Victorian era.

This is a profession that grew from industrialised society and the move to the cities and was very much based on the ideal of philanthropy. ‘Helping poor people’. A very female profession with its roots in the church – the middle classes raining beneficence on the deserving working classes.

So social work is a construct that is very much built within the modern era and by modern, read industrial.

And it seems like it has been trying to grow up for a good few decades.

When I was studying, I developed a weakness for the post-modern approach as it made and continues to make the most sense to me as a way forward.

Some of the ‘helping hand’ constructs need to be broken down to reduce some of the power issues that are always present but also built very much into the system. Using strengths-based models and user/carer led narratives to push away from the idea of the professional as expert and towards, at least from the social perspective, each person being their own expert. Where this is possible. There are situations that throw themselves up, like the role as ASW, that battle against these models – where do they fit in?

Of course, the overriding arch is ‘best interest’ . We are working in the ‘best interest’ of person x, y or z and therefore the means can justify the ends? That has to be the case to a certain extent. I’d say above all, and possibly something that doesn’t come across in the manner of my writing, I’m a pragmatic worker. I like to ‘do things’ probably more than I like to ‘talk about doing things’.

I’d say its why I’m a social worker rather than a counsellor.

As adult social care moves into a new era of personalised budgets and services being provided not by professionals making decisions about what is best, but by users and carers deciding what needs they are prioritising themselves and choosing the services themselves it can seem that the basis of care management in social work, at any rate, might be on a precipice.

I wonder sometimes if the personalisation agenda is the summation of a ‘post-modern’ approach to social work – coming only a good few decades behind the equivalent movement in the arts, literature, architectural world – but innovation in social policy is such a complicated matter and rarely edgy.

I have some doubts about personalisation – if it is to be a zero-cost ‘solution’ to the problems created by care-management, a lot more questions need to be answered than have been to date. I want it to work and am absolutely in favour of the axis of expertise being moved away from the professional or the state but I am not entirely convinced that that is the agenda of those who are pushing down this path. Until I see the proposals to make the service accessible to those who have primarily been excluded from direct payments, I will remain sceptical.

So no wonder documents and discussions are needed about the ‘role of the social worker’. A radical shift is needed. Is it happening though? And what are the reasons for the push?

I don’t have any answers but a consideration of the question is something that, I feel, can strengthen the profession if the questions are asked at a grass-roots level and not focused on the ‘management’ or ‘director’ level. People who are answering these questions on our behalf – the academics who might have last practiced on the ‘cliff-face’ decades ago.

One of the links I added to the side bar was the Barefoot Social Worker site. It’s a site I’ve been vaguely aware of for a while but I was reading through it more thoroughly last week and I’ve found it relatively inspiring – from my background of qualifying and practising in the 2000s and onwards.

It presents a Marxist/Radical perspective of social work as far as I can tell, that I learnt about and studied when I was initially training. It was presented as one of the views of social work practice theoretically but had been presented to me as an approach based a few decades ago which no longer remained relevant. I have to say the writing inspired me somewhat.

Searing writes that

Social work has always been ambivalent about its class position and its role in maintaining the social system as it is. State social workers are expected to use their professional relationship to keep people in line and this is often justified by wrapping everything up in the language of social inclusion which is often meaningless. Social workers cannot avoid the contradictory nature of their role but sometimes they need to take a stand and show which side they are on. In particular, they should be alert to increasing pressures on social workers to act more on behalf of the state than for the individual and strive to resist these pressures.

There are many ways this resonates. I do feel often like a pawn of the State and that my role is very much to act on behalf of the local authority, particularly in distributing resources.

We work from the inside to change and to effect change. For me, initially, I believed social work was very much concerned with social justice. It was the aspect of the job that appealed to me. I still believe it, but my perceptions have been changed by years of care management and being subjected to pen-pushing frustrations and seeing first hand some of the inequities of the system. I know I do some pieces of work differently to how my managers would like them to be done – particularly I might allot my time differently. But ultimately, although I answer to my management, I answer more immediately to my conscience.

Why does that choice have to be made?

Would my role be more effective from without the statutory sector?

What role does class have on the work I do?

My perception is that Social Work is possibly an aspirant middle class profession in that a lot of its roots are in the middle classes but it has a good proportion of practitioners who have a variety of personal backgrounds and experiences.

Social Work should not try to be Law or Accountancy. It has a different role to play in society.

I don’t know, I still don’t know.

And reflection. Reflection helps. In my own little way, I hope that the awareness of these issues and my reflection on them helps to temper some of the excesses that they might create. But it can’t eradicate them all as I have been reminded.

Saying that though, if it wasn’t me it would be someone else. Is that my own attempt to justify the role that I am playing? Possibly. I still have a way to go to reconcile these thoughts to a more coherent response.

The link between clumps or “tangles” of protein inside nerve cells in the brain and Alzheimer’s disease was first made over 100 years ago.

Later shown to be made up of a protein called Tau, the tangles build up inside cells involved in memory, destroying them in the process.

Rember, or methylthioninium chloride, is the first treatment specifically designed to target the Tau tangles.

Other treatments for Alzheimer’s tend to focus on combating a waste protein in the brain, beta-amyloid, which is known to form hard plaques. The latest work suggests targeting Tau may produce better results.

Although there have been other ‘wonder’ medicines in the past, this does seem to be heralded as a new development as the trials move into the next stage of trials with work also being done to look at the effects on prevention as well as a slowing of progression of Alzheimer’s.

“It is telling that this large trial was paid for by a pharmaceutical company. Public funding for dementia research is woefully inadequate. Cancer researchers receive ten times as much public funding as dementia scientists in the UK, yet dementia care costs are greater than those for cancer. We urgently need an increase in research funding if we are to offer hope to the 700,000 people in the UK who live with Alzheimer’s or other dementias.”

Of course, everyone is pulling on the same purse-strings so it’s hard to say one type of medical research should take precedence over another – and it’s hard not to make comparisons about availability of research money in one area as opposed to another – but it isn’t necessarily a situation of one or the other.

Pharmaceutical companies have obvious vested interests in funding research trials and while the best case would be for the research to be independent – at least the interests are openly stated. I for one, wouldn’t be too proud to use medication necessary as long as the research had integrity.

According to research published in the Guardian carried out at the University of Westminster by a couple of psychologists, Viren Swami and Eliana Hernandez – perceptions of wealth are linked to perceptions of beauty.

And according to the article I am among the ugliest people in London!

Of course, the study is interesting from the point that the wealthiest boroughs were most favourably perceived.

The findings shed light on how people come to think of others as attractive, the researchers claim. “There are two things this brings out. First, perhaps people in affluent areas have fewer disadvantages in life, smile a lot more, are less stressed and maybe they are seen as more attractive because of that. But secondly, the more important thing is that the rich get to control perceptions of what is attractive. Extreme thinness shouldn’t be attractive, but the rich in this country propagate that ideal through the media. The rich usually decide what is attractive for us culturally,” said Swami

The research paper can be read here, but for a price I couldn’t afford to pay – still I don’t need to, I can already see that where I live is right at the bottom of the list! I shouldn’t say this, but I’m almost proud.

The research was inspired partly by Francis Galton which was considerably less scientific as he writes in his autobiography (the quote from which is directly taken from The Galton Institute)

“I may here speak of some attempts by myself, to obtain materials for a ‘Beauty Map” of the British Isles. Whenever I have occasion to classify the persons I meet into three classes, “good, medium, bad,” I use a needle mounted as a pricker, wherewith to prick holes, unseen, in a piece of paper, torn rudely into a cross with a long leg. I use its upper end for “good”, the cross arm for “medium,” the lower end for “bad.” The prick-holes keep distinct, and are easily read off at leisure. The object, place, and date are written on the paper. I used this plan for my beauty data, classifying the girls I passed in streets or elsewhere as attractive, indifferent, or repellent. Of course this was a purely individual estimate, but it was consistent, judging from the conformity of different attempts in the same population. I found London to rank highest for beauty: Aberdeen lowest.

As the article describes, this is a model which works on triggers that are appropriate for the individual – Garner uses some examples in relation to her mother, Dorothy, who had dementia

“If while getting ready for bed, I noticed she had lost track of whether she was buttoning up the cardigan ready to go out or taking it off to go to bed, I would fiddle with my buttons alongside her and say ‘Oh good! No more travelling for us today! Glad we’ve got a bed for the night!’ I found that this simple cue was all she needed. Without it, she was inclined to get half-way through undressing and then start getting dressed again.”

SPECAL also teaches carers to avoid asking questions, because that means the person with dementia has to search their recent memories – and that can distress them. Carers are taught to supply reassuring information if the person with dementia asks questions. What the carer says is less important than the feelings their remark generates. The third rule is never to contradict, because that will also cause upset.

With Professor Trevor Harley at Dundee University, being quoted by the BBC as having said

“we found that if you probe the patient in the right way with appropriate questions that support them to search their stored knowledge, they can often generate more detailed information.

“That is, the knowledge isn’t always lost at all. Of course eventually the information might be completely lost, but this might happen much later than people have previously thought.”

As mentioned many times before, a lot of the work I do is with people who have diagnoses of dementia. This research, these writings, all seem to point to the need to be clear and not make assumptions about what a person can or cannot understand. It is important too, that we, as professionals, term phrases, questions and discussions in ways that can best be understood.

I’m curious enough about the SPECAL training in particular to investigate further. One of the practice issues we discuss at work from time to time is the need for honesty and how important it is, or not, to validate what is being said by a patient even if it is not based in the present reality.

I honestly think the path of causing the least upset is instinctively the path that would create the most positive interactions – but its good to see it laid out in research!

A couple of years back, I visited a residential home with a woman (that I’ll call A) who needed to move into residential care. She didn’t particularly want to, but she had accepted the need with a heavy heart. She didn’t have any other family so I took her to see some of the available places in the area.

There were some very modern and accessible, some friendly but none seemed to be homely to her.

Until we arrived in one other home. It was a converted house. We went to speak to the manager together and the manager had to extract an extremely large and very pampered long haired cat from the desk to meet us.

A’s face lit up. Fluffy flopped down onto her lap. The Manager apologised and said that Fluffy was so used to being patted and stroked by the residents that she just made herself at home on anyone’s lap.

A was sold though. She told me, though some tears, that she had always wanted a pet but her husband (deceased) had been allergic to cats. She was stroking Fluffy almost aggressively. Fluffy though, was happy.

I spoke to the manager, A being more or less oblivious to the conversation because she was concentrating her efforts on Fluffy.

Fluffy shifted around a little but levels of purring rose.

Needless to say, we had found a home that A wanted to move to. And she did.

The role of the IMCA was created by the Mental Capacity Act to provide a statutory advocacy service to someone who lacks mental capacity when serious decisions are made. The referral to an IMCA is mandatory in two circumstances

– Where serious medical treatment is considered

– Where a move or change to long term accommodation

and it may be used

– in adult protection proceedings

– Care reviews

With the exception of Adult protection, the service is aimed at those without family or friends to provide this support or voice.

In our team we’ve made some use of the services available to us and built up some good working relationships with our IMCA service but some of the results are curious all the same.

To summarize very basically, the most common types of referrals seem to be regarding long term care placements – which is wholly unsurprising to me, at least, as that’s the most common reason that I’ve made referrals.

The report though states that referrals for serious medical treatment is lower than expected. Stating that

Six hundred and seventy five people were referred to the IMCA service for representation in relation to serious medical treatment in England during the year April 2007-March 2008. This is an average of four and half cases per PCT in a year – or one every three months

Rather damningly, the reasons proposed were as follows

i Some doctors do not understand that there is a statutory duty to make referrals. They perceive it as discretionary.ii Some doctors do not agree with the statutory duty to make referrals. They choose to disregard it

With some IMCAs claiming that they were disregarded as some doctors felt that a non-medical person having input into a medical decision was ‘a waste of time’. Clearly an area in which further awareness and input needs to be concentrated.

Most IMCAs were positive about the input that they were able to provide and sufficiently confident that it was a new service and something in addition to other advocacy services or social work services who might have an advocacy role but have other demands.

One of the interesting cases given, an IMCA explains that they were able to find distant family of an individual merely because they had had hours to be able to investigate and go back through notes – something a professional might not have had time to be able to do.

Another exercise as a part of the review that the IMCAs were asked to do was to sum up their role. Many of them had been advocates prior to the new legislation and they claimed that the Mental Capacity Act had given them more power to ask questions on behalf of the people that they were advocating for – after all, their role is now legally entrenched. However they also claimed a powerlessness as ultimately their role is an advisory one and the decision-maker is still the decision-maker.

Personally I’ve found the IMCA reports provided to be useful for me to push my own commissioning and finance managers to provide care needed for an individual. In one situation, I discussed the recommendations that an IMCA made and it included the provision of a service that didn’t actually exist in our local authority – but by taking the report to our funding panel, I was able to point this out, markedly and explain that it was a poor reflection on our services that we were not able to meet the needs presented by an IMCA.

There are some interesting statistics at the end of the report which break down the referrals and decisions by month, need, decision type, ethnicity and finally a council-by-council breakdown of how many referrals were made.

I’m not sure if it’s the first time that an advocacy service has actually been created by legislation, I’d venture a guess that it is – but it won’t be the last time.

Indeed, the new Independent Mental Health Advocates created by the 2007 Mental Health Act can probably learn a great deal from the experiences of some of the IMCAs already in place.

Arriving in a new country with little notice or planning can be disorientating at best. Although some of the language may be familiar through years of study, it’s different when you hit the ground running, so to speak.

And it isn’t just language that is confusing. People use terms you didn’t find in the outdated text books at school which taught you how to ask for directions but not how to ask for a doctor.

People you meet, sometimes friendly, sometimes curious, sometimes stubborn and sometimes actively aggressive. Calling home is sometimes a sweet relief but sometimes, especially when you have no plans, no job and are running out of money fast – it can be the culmination of built up disappointments – and a reminder to your family that you haven’t really worked things out yet or that things aren’t as ok as you thought they would be. And you don’t want people at home to worry.

Everyone knows it’s hard adjusting to a new country, a new culture – but you knew you would be different.

But you weren’t.

It’s the simple things – not being able to say what you are thinking to anyone because mastery of the language is restricted to simple ideas. Will people think you are dim because you can’t say exactly what you are thinking in more complex terms?

People speak more quickly than your language instructor back home did. And they don’t pause for your mind to catch up.

On finding a job – it doesn’t always get better. People laugh at your accent, your word-finding difficulties. It’s amusing.

The frustration about not being able to communicate becomes stronger.

Which shops sell what things? Where do you go to post a letter? How do you access a doctor? What happens if you witness a crime?

All things you are familiar with at home become different – not just the language but the way of interacting. The ways that families work here – it’s just not the same. Men and women behave differently and not in the ways you are used to the gender roles at home.

Sometimes people are more open – sometimes more closed.

Sometimes you can feel more lonely than you have ever felt because although you have family, friends – they aren’t just.. well… there. You came and you need to stay.

You break a million new social conventions that you were never aware even existed and subject to more laughter, more joking – sometimes gentle ribbing, sometimes stronger.

Being aware of differences around you makes you far more aware of those people you had met at home – new immigrants, older immigrants – surrounded by different attitudes to those they had grown up around. Thrown into a different culture, different language, dialects, phrases that need to be learnt and put into context.

It’s get better you tell yourself. It can’t be that hard to adjust. And it does get better – after a few years – maybe.

–

But when you do go home, maybe after a year, or maybe two – there is nothing like those experiences to help you to understand what it’s like – what it could be like, to be in a different country, in a different state where nothing is quite like it was at home.

–

That’s what I was like for me anyway. I left the country seven years ago and came back again 5 years ago. It was the one of the best experiences I had – in retrospect – but at the time, well, it was exciting but also frightening. And lonely. Sometimes. I left not entirely sure if I was going to come back or not. In the end, I did. But when I go and see people who have moved here either through desperation or decision – I remember those days when I first arrived in my new country and think back to the feelings of exclusion which weren’t necessarily forced on me but that I felt at most turns and remember how even the most basic and seemingly obvious things become more challenging for me.